MEDICAL SUPPORT

CS 480P General Description of IV-D Medical Support Services

01/90 Revised 04/13/18 Training Completed 04/27/18

42 CFR 433.145, 433.147; 45 CFR 302.31, 302.33, 302.80, 303.30, 303.31 and 303.32; U.C.A. 31A-1-301, U.C.A. 62A-11-326; R527-201

 

 

Federal Regulations

 

Federal Regulations require the Office of Recovery Services/Child Support Services (ORS/CSS – the IV-D Child Support Services Program within ORS) to provide certain medical support services for all IV-A and Non-IV-A Medicaid recipients, and all eligible Non-IV-A applicants.

 

1.                   42 CFR 433.145 Assignment of rights to benefits—State plan requirements:

(a) A State plan must provide that, as a condition of eligibility, each legally able applicant or beneficiary is required to:

(1) Assign to the Medicaid agency his or her rights, or the rights of any other individual eligible under the plan for whom he or she can legally make an assignment, to medical support and to payment for medical care from any third party;

(2) Cooperate with the agency in establishing the identity of a child’s parents and in obtaining medical support and payments, unless the individual establishes good cause for not cooperating, and except for individuals described in § 435.116 of this chapter (pregnant women), who are exempt from cooperating in establishing the identity of a child’s parents and obtaining medical support and payments from, or derived from, the non-custodial parent of a child; and

(3) Cooperate in identifying and providing information to assist the Medicaid agency in pursuing third parties who may be liable to pay for care and services under the plan, unless the individual establishes good cause for not cooperating.

(b) A State plan must provide that the requirements for assignments, cooperation in establishing paternity and obtaining support, and cooperation in identifying and providing information to assist the State in pursuing any liable third party under §§ 433.146 through 433.148 are met.

(c) A State plan must provide that the assignment of rights to benefits obtained from an applicant or beneficiary is effective only for services that are reimbursed by Medicaid.

 

2.                   42 CFR 433.147 Cooperation in establishing the identity of a child’s parents and in obtaining medical support and payments and in identifying and providing information to assist in pursuing third parties who may be liable to pay:

(a) Scope of requirement. The agency must require the individual who assigns his or her rights to cooperate in—

(1) Except as exempt under section 433.145(a)(2), establishing the identity of a child’s parents and obtaining medical support and payments for himself or herself and any other person for whom the individual can legally assign rights ; and

(2) Identifying and providing information to assist the Medicaid agency in pursuing third parties who may be liable to pay for care and services under the plan.

(b) Essentials of cooperation. As part of a cooperation, the agency may require an individual to—

(1) Appear at a State or local office designated by the agency to provide information or evidence relevant to the case;

(2) Appear as a witness at a court or other proceeding;

(3) Provide information, or attest to lack of information, under penalty of perjury;

(4) Pay to the agency any support or medical care funds received that are covered by the assignment of rights; and

(5) Take any other reasonable steps to assist in establishing paternity and securing medical support and payments, and in identifying and providing information to assist the State in pursuing any liable third party.

(c) Waiver of cooperation for good cause. The agency must waive the requirements in paragraphs (a) and (b) of this section if it determines that the individual has good cause for refusing to cooperate.

(1) For establishing the identity of a child’s parents or obtaining medical care support and payments, or identifying or providing information to assist the State in pursuing any liable third party for a child for whom the individual can legally assign rights, the agency must find that cooperation is against the best interests of the child.

(2) With respect to obtaining medical care support and payments for an individual and identifying and providing information to assist in pursuing liable third parties in any case not covered by paragraph (c)(1) of this section, the agency must find that cooperation is against the best interests of the individual or the person to whom Medicaid is being furnished because it is anticipated that cooperation will result in reprisal against, and cause physical or emotional harm to, the individual or other person.

 

3.                   45 CFR 303.30 Securing medical support information:

(a) If the IV-A or IV-E agency does not provide the information specified in this paragraph to the Medicaid agency and if the information is available or can be obtained in a IV-D case for which an assignment as defined under § 301.1 of this chapter is in effect, the IV-D agency shall obtain the following information on the case:

(1) Title IV-A case number, title IV-E foster care case number, Medicaid number or the individual's social security number;

(2) Name of noncustodial parent;

(3) Social security number of noncustodial parent;

(4) Name and social security number of child(ren);

(5) Home address of noncustodial parent;

(6) Name and address of noncustodial parent's place of employment;

(7) Whether the noncustodial parent has a health insurance policy and, if so, the policy name(s) and number(s) and name(s) of person(s) covered.

(b) The IV-D agency shall provide the information obtained under paragraph (a) of this section to the Medicaid agency in a timely manner by the most efficient and cost-effective means available, using manual or automated systems.

 

4.                   45 CFR 303.31 Securing and enforcing medical support obligations:

(a) For purposes of this section:

(1) Cash medical support means an amount ordered to be paid toward the cost of health insurance provided by a public entity or by another parent through employment or otherwise, or for other medical costs not covered by insurance.

(2) Health care coverage includes fee for service, health maintenance organization, preferred provider organization, and other types of private health insurance and public health care coverage  under which medical services could be provided to the dependent child(ren).

(3) Cash medical support or the cost of health insurance is considered reasonable in cost if the cost to the parent responsible for providing medical support does not exceed five percent of his or her gross income or, at State option, a reasonable alternative income-based numeric standard defined in State law, regulations or court rule having the force of law or State child support guidelines adopted in accordance with § 302.56(c) of this chapter.  

(b) The State IV-D agency must:

(1) Petition the court or administrative authority to include health care coverage that is accessible to the child(ren), as defined by the State, and is available to the parent responsible for providing medical support and can be obtained for the child at reasonable cost, as defined under paragraph (a)(3) of this section, in new or modified court or administrative orders for support; and

(i) Allocate the cost of coverage between the parents.

(2) If health care coverage described in paragraph (b)(1) of this section is not available at the time the order is entered or modified, petition to include cash medical support in new or modified orders until such time as health care coverage, that is accessible and reasonable in cost as defined under paragraph (a)(3) of this section, becomes available. In appropriate cases, as defined by the State, cash medical support may be sought in addition to health care coverage.

(3) Establish criteria which are reflected in a record, to identify orders that do not address the health care needs of children based on—

(i) Evidence that health care coverage may be available to either parent at reasonable cost, as defined under paragraph (a)(3) of this section; and

(ii) Facts, as defined by State law, regulation, procedure, or other directive, and review and adjustment requirements under § 303.8(d) of this part, which are sufficient to warrant modification of the existing support order to address the health care needs of children in accordance with paragraph (b)(1) of this section.

(4) Petition the court or administrative authority to modify support orders, in accordance with State child support guidelines, for cases identified in paragraph (b)(3) of this section to include health care coverage and/or cash medical support in accordance with paragraphs (b)(1) and (2) of this section.

(5) Periodically communicate with the Medicaid agency to determine whether there have been lapses in health insurance coverage for Medicaid applicants and recipients.

(c) The IV-D agency shall inform an individual who is eligible for services under § 302.33 of this chapter that medical support services will be provided and shall provide the services specified in paragraph (b) of this section.”

               

5.                   45 CFR 303.32 National Medical Support Notice:

(a) Mandatory State laws. States must have laws, in accordance with section 466(a)(19) of the Act, requiring procedures specified under paragraph (c) of this section for the use, where appropriate, of the National Medical Support Notice (NMSN), to enforce the provision of health care coverage for children of noncustodial parents and, at State option, custodial parents who are required to provide health care coverage through an employment-related group health plan pursuant to a child support order and for whom the employer is known to the State agency.

(b) Exception. States are not required to use the NMSN in cases with court or administrative orders that stipulate alternative health care coverage to employer-based coverage.

(c) Mandatory procedures. The State must have in effect and use procedures under which:

(1) The State agency must use the NMSN to transfer notice of the provision for health care coverage of the child(ren) to employers.

(2) The State agency must transfer the NMSN to the employer within two business days after the date of entry of an employee who is an obligor in a IV-D case in the State Directory of New Hires.

(3) Employers must transfer the NMSN to the appropriate group health plan providing any such health care coverage for which the child(ren) is eligible (excluding the severable Notice to Withhold for Health Care Coverage directing the employer to withhold any mandatory employee contributions to the plan) within twenty business days after the date of the NMSN.

(4) Employers must withhold any obligation of the employee for employee contributions necessary for coverage of the child(ren) and send any amount withheld directly to the plan.

(5) Employees may contest the withholding based on a mistake of fact. If the employee contests such withholding, the employer must initiate withholding until such time as the employer receives notice that the contest is resolved.

(6) Employers must notify the State agency promptly whenever the noncustodial parent's and, at State option, custodial parent's employment is terminated in the same manner as required for income withholding cases in accordance with § 303.100(e)(1)(x) of this part.

(7) The State agency must promptly notify the employer when there is no longer a current order for medical support in effect for which the IV-D agency is responsible.

(8) The State agency, in consultation with the custodial parent, must promptly select from available plan options when the plan administrator reports that there is more than one option available under the plan.

(d) Effective date. This section is effective October 1, 2001, or, if later, the effective date of State laws described in paragraph (a) of this section. Such State laws must be effective no later than the close of the first day of the first calendar quarter that begins after the close of the first regular session of the State legislature that begins after October 1, 2001. For States with 2-year legislative sessions, each year of such session would be regarded as a separate regular session.

 

 

Definition

 

Health Care Insurance – as defined in U.C.A. 31A-1-301:

(79) (a) "Health care insurance" or "health insurance" means insurance providing:

(i) a health care benefit; or

(ii) payment of an incurred health care expense.

(b) "Health care insurance" or "health insurance" does not include accident and health insurance providing a benefit for:

(i) replacement of income;

(ii) short-term accident;

(iii) fixed indemnity;

(iv) credit accident and health;

(v) supplements to liability;

(vi) workers' compensation;

(vii) automobile medical payment;

(viii) no-fault automobile;

(ix) equivalent self-insurance; or

(x) a type of accident and health insurance coverage that is a part of or attached to another type of policy.

 

 

Services Provided

 

45 CFR 302.33 services to individuals not receiving title IV-A assistance states:

(a) Availability of Services.

(1) The State plan must provide that the services established under the plan shall be made available to any individual who:

(i) Files an application for the services with the IV-D agency. In an interstate case, only the initiating State may require an application under this section; or

(ii) Is a non-IV-A Medicaid recipient; or

(iii) Has been receiving IV-D services and is no longer eligible for assistance under the title IV-A, IV-E foster care, and Medicaid program.

(2) The State may not require an application, other request for services or an application fee from any individual who is eligible to receive services under paragraphs (a)(1) (ii) and (iii) of this section. If an individual receiving services under paragraph (a)(1)(iii) of this section refuses services in response to a notice under paragraph (a)(4) of this section, and subsequently requests services, that individual must file an application and pay an application fee.

(3) The State may not charge fees or recover costs from any individual who is eligible to receive services under paragraph (a)(1)(ii) of this section.

(4) Whenever a family is no longer eligible for assistance under the State's title IV-A and Medicaid programs, the IV-D agency must notify the family, within five working days of the notification of ineligibility, that IV-D services will be continued unless the family notifies the IV-D agency that it no longer wants services but instead wants to close the case. This notice must inform the family of the benefits and consequences of continuing to receive IV-D services, including the available services and the State's fees, cost recovery and distribution policies. This requirement to notify the family that services will be continued, unless the family notifies the IV-D agency to the contrary, also applies when a child is no longer eligible for IV-E foster care, but only in those cases that the IV-D agency determines that such services and notice would be appropriate.

(5) The State must provide all appropriate IV-D services, in addition to IV-D services related to securing medical support, to all individuals who are eligible to receive services under paragraph (a)(1)(ii) of this section unless the individual notifies the State that only IV-D services related to securing medical support are wanted.

 

NOTE:  45 CFR 302.33(a)(6) discusses the state’s option to provide paternity-only limited services in an intrastate case.  This option is not being adopted by ORS at this time.

 

The medical support services provided by CSS are listed below.

 

1.                   Petition the court or administrative authority to include a medical insurance provision in the support order per U.C.A. 62A-11-326 and 45 CFR 302.80.

a.                   U.C.A. 62A-11-326.  Medical and dental expenses of dependent children:

In any action under this part, the office and the department in their orders shall:

(1) include a provision assigning responsibility for cash medical support;

(2) include a provision requiring the purchase and maintenance of appropriate medical, hospital, and dental care insurance for those children, if:

(a) insurance coverage is or becomes available at a reasonable cost; and

(b) the insurance coverage is accessible to the children; and

(3) include a designation of which health, dental or hospital insurance plan, is primary and which is secondary in accordance with the provisions of Section 30-3-5.4 which will take effect if at any time the dependent children are covered by both parents' health, hospital, or dental insurance plans.”

b.            45 CFR 302.80 Medical support enforcement:

(a) The State plan may provide that the IV-D agency will secure and enforce medical support obligations under a cooperative agreement between the IV-D agency and the State Medicaid agency.

(b) The State plan must provide that the IV-D agency shall secure medical support information and establish and enforce medical support obligations in accordance with the requirements contained in §§ 303.30 and 303.31 of this chapter.

 

2.                   Gather medical insurance information for the Medicaid agency and CP and notify the Medicaid agency per 45 CFR 302.31(a)(3) which states:

When assigned medical support payments are received and retained by a non-IV-A Medicaid recipient, the IV-D agency shall notify the Medicaid agency whenever it discovers that directly received medical support payments are being, or have been, retained.

 

3.                   Enforce the medical insurance provision in the support order (45 CFR 302.80), see #1 above.

 

4.                   Collect and enforce medical support from the non-custodial parent (NCP) when the court has:

a.                   Designated a specific dollar amount in the support order as medical support; or,

b.                  Reduced uninsured medical expenses; e.g., cash medical support, to a sum-certain judgment.

 

NOTE:  ORS/CSS does not establish medical support orders with dollar amounts as described in (3) and (4) above as a service.  However, CSS will collect on a medical support obligation(s) after the parent has obtained a specific dollar amount in the order.

 

 

Limitation of Services

 

CSS medical support services are limited by R527-201-4 Limitation of Services, which states:

“ORS/CSS shall not:

1. pursue establishment of specific amounts for ongoing medical support,

2. initiate an action to obtain a judgment for uninsured medical expenses, or

3. collect and disburse premium payments to insurance companies.”

 

NOTE:  If the parent responsible for providing insurance maintains the required insurance coverage, then his/her employer is responsible to withhold the insurance premium and send the money directly to the appropriate insurance company.

 

 

Non-IV-A Medicaid Recipients – Cooperation Requirements

 

All Non-IV-A Medicaid recipients are required to complete a Third Party and Insurance Information Form (form 19) and an Assignment of Rights form to assign their medical support rights to the State as a condition of eligibility.  They must cooperate with CSS to:

 

1.                   Identify and locate the NCP/alleged father;

2.                   Establish paternity, a child support order, and an order for medical insurance;

3.                   Enforce medical insurance provisions; and,

4.                   Collect medical support, unless a Good Cause determination or other exception to cooperation has been made.   For more information on cooperation requirements and exceptions, refer to CS 059-3 Non-IV-A Medicaid-only Applicant/Recipient Cooperation Requirements.

 

 

Procedures – Non-IV-A Medicaid Recipients – Non-Cooperation

 

CSS must notify the Department of Workforce Services (DWS) or the Department of Health (DOH) that a Non-IV-A Medicaid recipient is not meeting cooperation requirements whenever s/he:

 

1.                   Does not provide the minimum required information on the NCP;

2.                   Retains medical support payments that are owed to the State;

3.                   Does not cooperate in securing a support order; or,

4.                   Does not cooperate in enforcing a medical support or medical insurance provision.

 

If you determine that a Medicaid recipient is not cooperating with CSS medical support requirements, notify DWS/DOH that a Non-IV-A Medicaid recipient is not cooperating with CSS.  DWS/DOH should remove the Medicaid recipient from the Medical card.

 

NOTE:  If the Non-IV-A applicant/recipient applies for Medicaid for a child(ren) only (i.e., s/he does not apply for Medicaid for herself/himself), s/he is not required to meet the CSS cooperation requirements in establishing paternity and/or child and medical support orders.  Therefore, if the applicant/recipient fails to cooperate with CSS in establishing paternity, if necessary, and/or child and medical support order, you may close the case Client Not Cooperating. 

 

 

Non-IV-A Medicaid Recipients – Continuing Services

 

ORSIS automatically generates a Continuing Services Notice to the former Non-IV-A Medicaid recipient within five (5) working days of the date CSS is notified that the recipient has closed off of Medicaid.  The notice informs the CP that CSS will continue to provide medical support services unless s/he notifies CSS that s/he wants full child support services or wants to terminate ALL services.  If the CP requests that the case be closed, close the case using the Request of Non-IV-A Applicant/Recipient of Initiating Agency closure reason.  Document the CP’s request in the case narrative.

 

NOTE:  CSS does not provide medical-only servicers to an applicant of IV-D services.  We only provide medical-only services when the recipient is on Medicaid only, or it is a medical-only continuing services case.

 

 

Non-IV-A Cooperation Requirements

 

Medical Support Services shall be provided in conjunction with child support services to applicants who are not receiving Medicaid.

 

The Non-IV-A applicant must cooperate with CSS to:

 

1.                   Identify and locate the NCP/alleged father;

2.                   Establish paternity, a child support order, and an order for medical insurance;

3.                   Enforce medical insurance provisions; and,

4.                   Collect medical support.

 

 

Procedures – Non-IV-A – Non-Cooperation

 

If the applicant fails to cooperate with CSS medical support requirements and you cannot take the next step on the case, you must:

 

1.                   Send the 60-Day Closure Notice to the CP; and,

 

2.                   Close the case Client Not Cooperating.

 

 

Fees

 

CSS does not charge fees or recover costs from Non-IV-A Medicaid recipients.  However, after the CP closes his/her Medicaid case, CSS will continue to provide child, spousal and medical support services in accordance with R527-201-5 (see subsection Cooperation Requirements above).  A check processing fee and federal tax intercept fee is charged to the CP on these types of cases.